69 - Posterior Calcaneal Heel Flashcards
Etiologies of posterior heel pain
- Retrocalcaneal bursitis
- Prominent superior calcaneal tuberosity- bursal process (Haglunds deformity or “Pump bump”)
- Insertional Achilles Tendinosis (IAT)
- Insertional Achilles Calcific Tendinosis (IACT)
- Posterior calcaneal exostosis
- Equinus
Clinical assessment of posterior heel pain
- Thorough medical history
- HPI
- M/S; Biomechanical exam
o Equinus
o Cavovarus
o Over-pronation/pes plano valgus
o Radiographs?
o Specific location of pain - NOTE: Don’t just treat x-ray, treat patient based on exam and history
Retrocalcaneal bursitis
- Inflammation of the bursa between Achilles and calcaneus
- Hallmark pain- anterior to Achilles and superior to the calcaneal tuberosity
- Common in runners/athletes – overuse injury or INCLINE running
- NOTES: If patient has an inflammation of the bursa – you can imagine that if you are running uphill, it is pinching the normal anatomic bursa, causing pain and additional edema
- Can cause increase in inflammation of the tendo calcaneus
- When you squeeze side to side just anterior to the Achilles on the posterior calcaneus, a patient with retrocalcaneal bursitis will experience high levels of pain – HALLMARK SIGN***
Signs and symptoms of retrocalcaneal bursitis
- Pain with compression ANTERIOR to Achilles tendon just proximal to insertion – this is called the “two finger squeeze test”
- Edema and/or Erythema in the bursal region
- Pain with activity
- Burning
Notes on signs and symptoms of retrocalcaneal bursitis
NOTES: There will be some times of diffuse edema and swelling to the area, so you NEED to look at both sides of the extremity
o It may be relatively normal until you compare it to the other side
o Often times patients will describe a burning sensation to the area
o Increased pain with activity (going up steps really bothers it)
Treatment of retrocalcaneal bursitis
- Rest, Ice, activity modification
- Heel lift/orthotics
- NSAID’s
- Offloading with cam boot
- Injections – Use caution-Make sure ONLY inject into the bursal sac and warn patient of risks – Possibly need to protect after with decreased activity or non-WB
- PT
- Surgery
Surgery options for retrocalcaneal bursitis
o Open resection of bursa
o Endoscopic
o Calcaneal osteotomy/exostectomy
Notes on treatment options for retrocalcaneal bursitis
o Heel lift – Raises heel out of shoe to prevent rubbing and releases some tension on the Achilles
o Downhill creates the posterior process is pushed forward to decrease shearing forces
o Injection is not my first go-to, usually do very conservative first, but does do it
o Do NOT inject into tendon, but because the bursal process does get inflamed, when you go in there surgically there is a lot of red, blood, inflammation, etc.
o Have them stop running for a period of time
o Can either just go in and take out the bursa or go in and take out the exostosis
o If you go in laterally you can go in without damage
Haglund’s “pump bump” deformity etiology
o Anatomic variant o Biomechancial (i.e. varus)
Description of Haglund’s “pump bump” deformity
o May involve the entire posterior aspect
o Different than IACT
o No osteophytes (could be present concomitantly with different etiology/pathology)
o May present with retrocalcaneal bursitis
True Haglund’s deformity
NOTE: Students tend to want to call anything on the back of the calcaneus as a Haglund’s deformity, but it’s not
o A true Haglund’s when we are talking x-ray and we see a bony prominence on the superior aspect of the posterior calcaneus – Needs to meet x-ray measurements
o Sometimes the term is used loosely as any bump on the back to the heel – this is actually a “pump bump” but it doesn’t have another name, so people will call this a Haglund’s deformity too
Signs and symptoms
- Usually irritation from shoe gear
- Skin irritation/breakdown – possibly from high heel shoes
- Women ~16-35 (can be present at any time, male or female)
- NOTES: Shoe gear irritation is huge – high heel shoes will rub on this area
- Hyperkeratosis is common, especially in older women – the hyperkeratosis is irritating
Physical examination
- “Pump bump”
- May have erythema and/or edema but not very common
- Pain from shearing
- May have pain on palpation (sometimes only painful with/after shoe wear)
- Hyperkeratosis
Example of IACT
This is NOT Haglund’s primarily: IACT with concomitant Haglund’s
- There is a calcification of the tendon
- The pain is not primarily from the Haglund’s deformity
- IACT = Insertional Achilles Calcific Tendinosis
Haglund’s deformity radiographic evaluation
Lateral, oblique, axial
o Measurements may not be of any significant benefit
Prominent posterior superior aspect-Bursal Process
o Fowler And Philip Angle 75° (65°)
o Total Angle 90° - Ruch
o Parallel Pitch Lines - Pavlov
